Bringing order to the asthma clinic

The next data extract is a transcript of a video-recorded interaction between a nurse and patient at the opening of an annual asthma check. It involves the completion of a template, and on this occasion this was recorded through simultaneous screen capture (Extract 2). I introduced videorecording of consultations only after spending a considerable amount of time 'lurking and soaking' as an ethnographer (Werner and Schoepfle 1989) and it was during observations of the chronic disease clinic that I had experienced the influence of the template most powerfully.

Templates are electronic forms designed to support management of individual patients ('primary use' of data) and produce aggregated data, e.g. on organisational performance ('secondary use'). Chronic disease management is the main area of incentivisation within QOF, and the relevant clinical indicators are inscribed in the template. For example, in asthma care QOF requires a record of smoking status and evidence that an asthma review has taken place. QOF guidance outlines what the review should include.

Extract 2 Opening of nurse-patient asthma

Time

N/P

Spoken word

Bodily conduct

EPR screen

01:08

N

So realiv straightforward. (0.4)

N puts paper on desk

N rotates body and gaze to face P, her hands on her lap.

P looking at N

Summary

screen

01:09

N

P

Asthma assessment (0.4)

Okay

P nods

01.11

N

to see how vour asthma's do:ing:

N raises both hands in front

01.13

N

what you're doing w- with it when it's good, what you do with it when it's ba:d,

(0.2)

have you any problems with your tinhalers (0.4) .hhh (0.5)

N uses fingers to count on 'good' 'bad' 'problems'

N hands open out in front of her

01.19

N

P

N

Very straightforward

stuff

Oka[y

[all right?

.hhh

N hands to lap P nods

01:21

N

U:::hm

N rotates body & gaze to screen, hands on lap

01:23

N

What I've got here

N gestures her open hands towards the screen

01:24

N

Is that you're on:: (0.4) a purple inhaler?

N rotates back towards P, bringing hands together

01:26

P

(0.2)

Yeh (.) uhm (0.2)

seretide.

P glances briefly towards the screen

First, some comments about my approach to transcription which is an early step in analysis. Transcription, albeit time-consuming, is an opportunity to become immersed in the data, to decide what may be relevant to transcribe and what level of detail is necessary (Bailey 2008). For me this began with repeated viewings of video data and included decisions about how to transcribe bodily conduct and details of the EPR screen. I have adapted an approach suggested by Jewitt for transcription of multimodal data, with different modes presented in adjacent columns, using time as an anchor (Jewitt 2006). I adopted Jefferson conventions for transcription of the spoken word (Atkinson and Heritage 1984) aiming to balance clarity, completeness and readability within a multimodal orientation. Readers interested in learning more about the transcription of multi-modal data may like to consult the MODE online transcription resource, to which I have contributed some of my reflections on this process (National Centre for Research Methods 2012).

Returning to this data extract, we see that the nurse frames the consultation as an assessment, setting up an evaluative tone for the meeting. First she says it is to see how 'your asthma's doing’ (an assessment of the asthma). She then reformulates this as 'what you're doing with it when it's good, what you do with it when it's bad’ (an assessment of the patient's practices). This metaphorical separation of disease ('it') from patient ('you') was common, and the use of templates across a wide range of chronic diseases appeared to encourage this disease-specific, task- oriented approach. The evaluative frame anticipates an enquiry which goes on to incorporate inhaler technique, smoking status, concordance with medication and peak flow measurements. At 1:08 and 1:19, the nurse emphasises that it is really or very straightforward. At 1:13 she counts on her fingers a three-part list, flagging the linearity of what is to follow and setting out what needs to be achieved. On the one hand this might be interpreted as reassurance, but it is a reassurance about what the patient may expect of the structure or order of the clinic, not a reassurance that his specific concerns will be addressed (Swinglehurst et al 2012). Evidence for this interpretation follows immediately after this data extract, when the nurse gestures towards the computer again as she explains 'What I've got here is some questions that I - I need to ask you ... they're fairly straightforward ones but what they tend to do with is that they will flag up whether there >actually< we have got what w- what I would call breakthrough symptoms.' This brings an institutional imperative to the encounter ('I need to ask you’) as she highlights once again the 'straightforward' nature of the task, invoking the electronic template as the origin of the questions, by gesturing towards the screen. As the patient begins to show the nurse how he uses his inhaler, he coughs loudly five times, beats his chest demonstrably with his hand and announces:

Patient: 'I do suffer very badly from phlegm in the mornings ...

which I presume is part and parcel of having asthma.' Nurse: 'It can be (.) yeah which (0.4) anyway I - we'll talk about

that in a minute ... we'll do the inhaler first.'

The structured inventory of questions has already become apparent in this consultation, and the patient weaves his own concerns into the assessment of 'inhaler technique' using elaborate emphatic gestures. However, the nurse quickly steers the patient's activity back to the institutional script and does not revisit the issue of the morning phlegm. She does go on, at a later stage in the consultation, to enquire specifically about asthma symptoms, but not until almost 16 minutes into the 19 minute consultation ... and when prompted by a template field reading 'night symptoms'.

 
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